RICHARD ABLIN
Palgrave Macmillan, 2014, 262 pages, $42.50 (hb)
When Richard Ablin, then
a young immunologist and now a University of Arizona pathology professor, discovered,
in 1970, an enzyme specific to the prostate gland (prostate-specific antigen or
PSA) whose elevated levels in blood indicate an abnormality in the gland, he
had no idea how a simple blood test would go on to become the foundation of a
“profit-driven public health disaster” through prostate cancer screening.
Elevated PSA levels
can be caused by prostate cancer but also by infections, aspirin, riding a
bicycle, ejaculation and normal, age-related prostate enlargement. The PSA test is organ-specific not
cancer-specific yet it has become ubiquitous as a diagnostic cancer-detection
tool leading to many unnecessary and dangerous treatments.
Most prostate
cancers are slow-growing and can be safely left alone because prostate cancer is
an older man’s disease and nearly all men will die with it but few of it,
succumbing instead to other diseases of ageing (80% of men in their seventies will
have prostate cancer but only 3% will die because of it). Nearly all prostate cancers will do absolutely
no harm unlike, however, the screening and treatment for them.
Because of the PSA
blood test’s worse-than-chance inaccuracy (15% of its negative results are
wrong, 60-80% of its positive results are wrong), the test requires a follow-up
biopsy of prostate tissue. The biopsy causes
bleeding and pain and, with the biopsy needle passing through the bowel,
carries a risk of potentially fatal infections of genito-urinary organs and of
the blood.
The treatments that
follow biopsy have their own suite of adverse effects. Surgical removal of the prostate gland
(prostatectomy) carries a high risk of urinary incontinence and erectile dysfunction,
radiation therapy causes inflammation of the bowel, and chemotherapy is not
renowned for its pleasures.
The associated waste
of health resources and men’s well-being is staggering. There are an annual 30 million PSA tests (at
$80 a pop) in the US, a million biopsies (at $2,000 each) and 100,00 prostatectomies
(each fetching $30,000) for a total cost of US$28 billion, coming from the pocket
of patient or taxpayer. All of this expense
is for little clinical benefit – one thousand men have to be PSA-tested to successfully
prevent just one prostate cancer-related death.
Yet, the PSA test has
become embedded in routine men’s health checks – all because of money, says
Ablin. Entrepreneurial medical
scientists and the biotechnology industry saw the potential of mass screening
to turn the PSA test, and its more expensive successor blood tests and cancers treatments,
into a cash-cow, to be milked by pathology, urology, radiotherapy and oncology practices,
medical device companies and ancillary medical businesses (erectile
restoration, incontinence pads).
From blood test to
diaper, “the prostate cancer business is a self-perpetuating industry that
creates a need for its services and products”.
The only difference any of this over-servicing makes is to the corporate
medical bottom line, not to prostate cancer mortality.
Corporate influence
over government health watchdogs also creates a regulatory culture “that looks
the other way” over dodgy data and clinical risk, whilst medical industries finance
most clinical trials and dollar-dazzled doctors-for-hire have a financial
interest in plugging the PSA test. The
corporate dollar also feeds patient advocacy groups whilst marketing triumphs over
evidence as charismatic survivor testimonials and sports celebrity endorsers
manipulate millions of men, playing on the fear of cancer, onto the prostate
cancer conveyor belt with its unnecessary, costly and dangerous, but above all,
lucrative, testing and treatments.
“Powerful interests
knowingly misused the PSA test to generate huge profits”, concludes Ablin. Be informed, is his warning to men when their
GP talks prostate. Ablin’s story of “greed
and damaged men and government failure” is a good place to start.
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